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Drainage is of paramount importance, even more crucial than appropriate antibi-
otic selection;however, cultures should be obtained to guide antibiotic selection. If
the combination of drainage and antibiotic agents fails to rapidly resolve the prob-
lem, operative exploration should be considered to rule out an infected foreign
body. Cotton used to plug the external auditory meatus has been known to drop
into the wound and should be accounted for in the sponge and needle counts. In
severe infections of the face, thorough irrigation, debridement of any nonviable
tissue, and wide drainage is generally effective, in addition to administration of an
appropriate antibiotic. Hospitalization and intravenous antibiotic therapy are rarely
needed, but anything less than rapid resolution of the infection should be treated in
this manner.
PAROTID FISTULA
Parotid injury has become a more common event with face-lift techniques that
involve dissection in the sub-SMAS plane. Unfortunately, it is even more likely
when the SMAS has been previously elevated as in some secondary face lifts.With
any secondary facial procedure the parotid is at greater risk of injury because of al-
tered anatomy and scar.25,26 The gland is at highest risk over its super cial lobe just
at the mandibular angle. The super cial fascia can usually be separated from the
parotid fascia unless the plane has been previously obliterated surgically. Actually,
raising both the super cial fascia and the parotid fascia in continuity is sometimes
advantageous when the super cial fascia is thin, because this adds strength for the
deep tissue xation. However, one is dissecting right on top of the glandular lob-
ules of the parotid, which can look very similar to the sub-SMAS fat and is there-
fore susceptible to injury.This is how most parotid injuries occur.The duct is rarely
injured but can be obstructed if the gland is torqued with suture xation.
The key to management is to recognize the injury to the parotid at the moment it
occurs so that the plane of dissection is immediately corrected.The injured parotid
is simply coagulated with the electrocautery or rarely, oversewn with ne sutures if
the injury appears to enter the terminal ductules. The area is drained and com-
pression applied for 48 hours. If there is obvious saliva appearing in the drain, it
should be left in place until the output is minimal. Generally, these stulas are self-
limited as long as the duct is not obstructed. Sialography or duct endoscopy has
been reported to be helpful in reopening an obstructed duct.26,27
Injuries late in the postoperative period are diagnosed by a swelling and uid col-
lection over the parotid that on aspiration yields a high amylase titer. Generally, the
patient is afebrile.The swelling often increases with eating. It is managed by insert-
ing a closed suction drain, adding a pressure dressing, and administering antibiotic
agents. Atropine and glycopyrrolate have been reported to be helpful for their anti-
sialagogue effects.25

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NERVE INJURY
Any branch of the facial nerve can be injured during a face lift.
With the altered anatomy from primary surgery, deeper dissections beneath the
SMAS during secondary face lifts risk injury to the facial nerve.28 The frontal
branch is the most commonly injured branch followed by the marginal mandibu-
lar, and the buccal. Although severed branches do occur, the more typical injury is
a result of traction or thermal injury from the use of cautery in close proximity.The
vast majority of nerves which are still in continuity recover in time although this
can take up to a year or more. Most recover within two weeks to three months.
When frontal branch weakness is noted postoperatively and persists beyond one
month, I favor the use of Botox to weaken the normal side if the patient will ac-
cept it while the injured side recovers. Often as the Botox wears off, the nerve has
recovered on the injured side and symmetric movement is reestablished.
If the nerve has not recovered by one year, a more permanent solution is to do ei-
ther a direct or endoscopic brow lift on the affected side and on the normal side if
indicated. A similar strategy can be used for the marginal mandibular branch with
weakening of the depressor anguli oris (check muscle name) on the normal side
with Botox. Resection of this muscle has been reported for perioral rejuvenation
and could be considered if the asymmetric smile persists beyond one year. Other
solutions are discussed in Chapter 26. Injuries to the great auricular nerve are usu-
ally managed conservatively as often sensation will spontaneously return.
DYSPHAGIA
Dysphagia is attributable to the platysmal tightening which is a dramatic change for
patients who are accustomed to a loose neck. Diazepam is effective for sympto-
matic treatment early on, and no surgical intervention is ever indicated as the mus-
cle always relaxes with time.

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EMOTIONAL ISSUES
Recovery from a face lift is an emotional roller coaster for some patients. The ef-
fects of anesthesia, steroids and other medications, as well as fear regarding eventual
appearance can take a serious toll on the emotional well-being of the face-lift pa-
tient. Preoperative education can help prepare the patient for “the blues” that fre-
quently accompany the recovery process. A relationship with a clinical psychologist
in your community can pay great dividends if intervention seems to be necessary.
Other patient issues are discussed in Chapter 3.
AESTHETIC EVALUATION OF THE PATIENT
SEEKING A SECONDARY FACE LIFT
With better understanding of the aging process, we now know that repeated pulling
of skin, especially in a disadvantageous direction, will not restore a youthful ap-
pearance, but rather yield an appearance that belies repeated surgery and may be
exceedingly dif cult to correct.29,30 The “lateral sweep” of the lifted lateral cheek
and jowl but uncorrected midface is a classic example of this. Therefore patient
evaluation must begin by careful analysis of which features are yielding an aged
appearance. The upper third of the face as well as eyelid surgery is discussed else-
where in this volume and therefore, will not be covered here. (See Chapters 12, 13,
17, 18 and 19.)
Quality and texture of skin
Degree of skin relaxation
Degree of fat atrophy with residual
hollowing
Facial asymmetries
Depth of nasolabial, labiomental, and
nasojugal creasing
Ear and earlobe malposition, ptosis, and
deformities
Tragal de nition and position
Hairline shifts or hair loss
Visibility and quality of previous scars
Factors to Be Considered in Secondary Facial Rejuvenation
Other aging features not previously addressed
including perioral lines, thinning and
lengthening of lips
Platysmal banding and laxity
Submandibular gland prominence
Chin shape and ptosis
Contour deformities of the neck resulting
from excess fat in neck or jowls, either
above or below the platysma
Malar attening
Digastric muscle prominence
Dentition

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In this patient with sun-damaged skin and facial wrinkling, the wrinkles run in a
cephalad direction as the result of a previous face lift. This problem usually be-
comes more evident with animation and when the patient exes the neck.
It is usually a mistake to immediately conclude that what every patient
must have is your de nitive face lift, as if whoever did it the rst time
might be lacking your skill.
We all have patients who do not get as long-lasting a result as we would have liked.
In fact, some heavy-jowled or “bull-necked” patients should be told in advance
that an angular fashion-model type of neck could never be achieved for them. In-
stead, they may be candidates for an early retightening because of the loss of good
skin elasticity.

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This 66-year-old patient has considerable loss of skin elasticity with very loose tis-
sues in the neck and a rounded facial appearance.This type of patient is a likely can-
didate for an early secondary correction, even as early as 1 year after the primary
procedure, because of the likelihood for recurrence of jowling and laxity. She must
be informed of this in advance to avoid dissatisfaction and unrealistic expectations.
This patient’s operative sequence is shown on pp. 295-297.
Further, many patients may be seeing you because they have heard you are not a
surgeon who immediately wants to do another face lift on everyone.You now have
multiple different approaches available to you, so the rst rule is listen to your patient!
Then ask,“What is it about your face that is beginning to bother you?” and “Were
these features improved after your rst face lift?” Starting with questions like these
will assist the plastic surgeon in tailoring valuable consultation time toward the pa-
tient’s primary concerns rather than discussing all sorts of items that the patient
will simply not consider. Nevertheless, the consultation is also an opportunity to
help educate the patient about procedures or treatments that will give lasting im-
provement versus treatment options that he or she may have heard about but for
which the patient is not a candidate. Botox and llers are not going to give a face-
lift–like result, quite obviously, but some patients are confused about issues such as
these.
In recent years, much more attention has been paid to the midface as well as vol-
umetric shaping of the face.31,32 These are issues that might not have been addressed
during the patient’s initial face lift. Of course, if you performed the original proce-
dure, you have easy access to the records for what was done. If the original surgery
was done by someone else, you may not be able to determine exactly what was
done the rst time around. However, if the assessment reveals an aged midface ap-

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pearance, you will need to address this at the time of surgery. Also, the addition of
fillers, including autologous fat for volumetric replacement, is more commonly
done today than just a few years ago. Therefore it is likely that the patient has not
bene ted from some of the newer technologic innovations that plastic surgeons
now have available to them.
Often the quality of the skin has either further deteriorated or has never been
treated in a secondary patient.This may be the primary source of concern for the
patient, and improvement is more a matter of resurfacing, lling, or skin care, which
are fully discussed in Chapter 15.
TECHNICAL APPROACHES FOR
A SECONDARY FACE LIFT
The approach to secondary rejuvenation ows out of the previous comments on as-
sessment.The plan should encompass correction of as many of the problems listed
earlier as is practical, given the desires of the patient and limitations of time, -
nances, or comorbid conditions. If the patient desires a second facial rejuvenation,
then many of the conditions discussed earlier can be addressed through the open
approach.
INCISIONS
If the neck has retained a youthful appearance, a postauricular incision can some-
times be avoided, although if the previous scar is already there, little harm is done
by reopening it. Certainly, if the position of the previous scar is disadvantageous
and visible or if there is a step-off in the posterior hairline, then it should be opened
and corrected. It is desirable to try to keep the transverse portion of the postauric-
ular scar at or above the upper third of the ear. I prefer to open the old incision and
undermine the skin aps and then determine how far up I can move the postau-
ricular incision before excising the normal skin above the old incision.

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Anterior incisions should almost always be anterior to the sideburn and posterior
to the tragus (at least in women) to avoid further shifting of the sideburn and hair-
line posteriorly and to reduce the visibility of the tragal scar.The anterior sideburn
incision can be designed as a W-plasty and be beveled along the hair follicles to
improve the chances that viable hair will grow up through the scar. Alternatively,
the vertical portion can be placed inside the hairline, so in some cases, where little
skin is removed, the resulting scar will be hidden by the natural hairline.33
The best scars will result from a tension-free closure, so attention must be paid to
releasing tension from the earlobe and from the tragus to prevent secondary defor-
mities.The best anchoring point for the skin ap is the root of the helix of the ear
and the top of the postauricular incision, if one has been made.

UNDERMINING THE SKIN
Whenever possible, I prefer to limit the undermining to the malar area, the mid-
cheek, the jawline, and lateral neck area. The undermining should be precise and
under direct vision or using the knife, the thickness of the skin ap must be kept
even. Most patients will require elevation of the malar area, and exposure to this re-
gion is necessary. If the neck can be managed with liposuction alone, I leave it
closed to avoid hematoma dissecting into this region. Obviously, if heavy, active
platysmal bands are present or if one feels compelled to work on the digastric mus-
cles, subplatysmal fat, or submandibular glands, the neck will require undermining
through a separate submental incision.
THE SMAS
Once the SMAS is exposed, I determine whether it requires separate dissection as
a ap or can be simply plicated. If I know that a SMAS ap was previously done or
if the patient is elderly or the SMAS is thin, plication is preferable to SMAS under-
mining. If the SMAS appears substantial and manual distraction of it does not pro-
duce the desired result at the nasolabial fold and corner of the mouth, I prefer to do
the SMAS elevation and anchoring of the malar fat pad to the malar periosteum.
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Incisions for an “extended SMAS dissection” are shown.

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The typical extent of SMAS dissection in the
malar region, cheek, and neck is illustrated.To ob-
tain adequate mobility with redraping, the SMAS
in the malar region must be freed completely from
its zygomatic attachments. To reelevate jowl fat
into the cheek usually requires division of both
the zygomatic ligaments as well as the upper por-
tion of the masseteric cutaneous ligaments. The
SMAS in the cheek below the parotid duct is usu-
ally elevated to the anterior border of the masseter
muscle; occasionally division of the lower masse-
teric cutaneous bers is required. The SMAS in
the neck is elevated from the tail of the gland, ex-
tending anteriorly within the areolar plane deep to
the platysma, until adequate mobility is obtained
to allow contouring of the submandibular and
submental regions. The key to SMAS elevation is
to obtain adequate mobilization that allows reele-
vation of facial fat without undue tension.
It is often necessary to extend the malar SMAS
dissection more peripheral than the subcutaneous
dissection to obtain adequate ap mobility of the
soft tissues lateral to the nasolabial fold. This por-
tion of the dissection is easily performed by in-
serting the scissors in the plane between the su-
per cial surface of the elevators of the upper lip,
and the overlying subcutaneous fat and bluntly
dissecting toward the nasolabial fold. As long as the
scissors remain super cial to the elevators of the
upper lip, motor nerve injury will be prevented.
Usually three or four passes are required to obtain
adequate ap mobility.

In SMAS redraping in the cheek, note that some of
the excess SMAS is transposed posterior to the ear to
affect contour in the submental and submandibular
regions through lateral tension. It is important to se-
cure this ap to the mastoid fascia, which is an immo-
bile structure, rather than to the fascia overlying the
sternocleidomastoid muscle, which is a mobile struc-
ture. Final closure is shown on the bottom image.
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The excess SMAS, rather than being excised, is rolled on itself, forming a double
layer of SMAS thickness. Once the roll has been formed, it is xated to the perios-
teum of the zygomatic buttress using permanent sutures.
It is essential to obtain a secure intraoperative xation; xation is as
important as adequate SMAS mobilization.

The subcutaneous undermining for the malar fat pad elevation proper reaches an-
teriorly to a vertical line dropped from the lateral canthus and superiorly to the
level of the lateral eyebrow. Elevation of the malar fat pad in the vertical vector is
obtained with suspension sutures to the super cial temporal fascia in front of the
temporal hairline at the level of the lateral brow.
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The lateral SMASectomy approach popularized by Dr. Dan Baker takes advantage
of the looser SMAS substance in the midcheek region to produce effective eleva-
tion of the nasolabial fold and corner of the mouth.This submalar tightening is an
excellent way to tighten the loose jowl.

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The weaving suspension sutures popularized by Tonnard and Verpaele are designed
to produce a strong vertical vector to the SMAS and work well in patients who
have some degree of laxity of the SMAS without undermining.
The malar fat pad suspension suture is shown. A horizontal mattress suture is placed
so that greater tension is exerted along the superior margin of the pad to produce
a central vector of lift that corrects the central infraorbital hollowing of the midface
catenary. Simultaneously, the suture lifts the fat pad apex along a vector perpendic-
ular to the prominent nasolabial fold.

Plication can be done in a variety of ways.Vertical suturing to “stack” the malar or
submalar area with fat is particularly effective for jowl correction as described by
Little.31 This submalar imbrication can give the illusion of malar augmentation by
accentuating the inward curve beneath the malar prominence (the “ogee” curve).
THE NECK
Overresection of fat from the neck results in a skeletonization of the cervical area
that is very dif cult to correct. I know of no way to restore adequate thickness of
subcutaneous fat between the platysma and skin other than autologous fat injection.
For this reason, I am conservative about fat removal in the neck, whether in a pri-
mary or secondary procedure. Subplatysmal fat is removed during secondary pro-
cedures only when necessary to try to develop a cervicomental angle which is ac-
ceptable in a short heavy neck. Removal of portions of the submandibular gland or
the anterior belly of the digastric muscle have been reported to assist in sculpting
the neck.34-36 Repairing the platysma using a vest-over-pants technique is also help-
ful in developing an aesthetic cervicomental angle in a patient whose platysma
muscle is quite redundant.
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The platysma is exposed along the anterior aspect of the neck.

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After the platysma has been mobilized, the muscle edges are overlapped and the ex-
cess muscle is excised. It is important for the resection to be conservative so that the
edge-to-edge approximation of the platysma will be performed under tension that
is not too great.
Edge-to-edge approximation of the pla-
tysma muscle, extending from mentum to
the thyroid cartilage, is performed.This long
plication greatly enhances the surgeon’s
ability to tighten the platysma and to con-
form the platysma closely against the oor
of the mouth and the thyroid cartilage. A
better foundation for the redraping of cervi-
cal skin is thus produced.

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Following edge-to-edge approximation of the platysma from the mentum to the
cricoid cartilage, some form of muscular release is performed.This release consists
of a horizontal cut extending from the midline to the anterior border of the ster-
nocleidomastoid muscle.The key to platysma transection is to perform it as low in
the neck as possible and just caudal to the last suture that has been placed in mus-
cular plication.

Unusual hypertrophic scarring is seen in this patient following a primary face lift
that involved both the preauricular segment and the postauricular sulcus. Correc-
tion is possible only by careful excision and ap readvancement, a closure free of
tension, and injection of triamcinolone (Kenalog 10 mg/ml), repeated every 4 to
6 weeks as necessary to avoid recurrence.
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SKIN R EDRAPING
To avoid the lateral sweep appearance of the cheek, the area must be carefully ob-
served as the skin is redraped. Usually, satisfactory elevation of the midface com-
bined with a more vertical vector of the skin redraping will eliminate this appear-
ance of the skin. Sometimes laser resurfacing is helpful to produce some skin
retraction and improvement of surface wrinkling. As noted earlier, keeping tension
off the earlobe and tragus is essential.This is accomplished by good SMAS support.
Deep sutures away from the ear will help keep the stress off the ear and allow it to
stay or rotate back to its normal axis.The earlobe should be released and inset free
of tension on top of the resupported skin ap. A deep suture from the dermis of the
skin ap anchored to the inferior portion of the concha under the earlobe will
keep the stress off the earlobe. If there is insuf cient skin to cover the tragus, a small
ap from the cheek ap superior to the tragus can be rotated back down to cover
it without distorting it away from the external auditory canal.

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PATIENT EXAMPLES
Staged Facial Rejuvenation
This 40-year-old patient requested facial improvement but was not ready for a face
lift. Her initial treatment was a reduction in lower facial volume using ultrasonic
lipocontouring of the jowls and neck area.

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Five years later, she noted laxity through the lower face and neck and requested
tightening. An extended SMAS face lift was performed, with considerable improve-
ment along the jawline and malar areas. Her reoperation was made easier by the
previous defatting of the lower third of her face; however, increased scarring was
encountered in the facial undermining as a result of her previous liposuction.The
result is shown 2 years postoperatively.

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This sequence demonstrates the staged procedures in a 67-year-old patient under-
going facial rejuvenation. Analysis of her preoperative appearance reveals a very
heavy laxity through the jowls and cervical area. She was counseled preoperatively
that an early retightening of the neck would be a strong possibility because of the
dif culty in maintaining the tightening.

Unfortunately, her postoperative course was complicated by a neck hematoma that
developed as a solid, brous mass as a result of incomplete drainage. Even after 6
months, the brous cord failed to soften or dissipate. Under local anesthesia the
mass was excised as shown.
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Ultimately, a secondary lift procedure was performed to improve the jawline; sev-
eral SMAS plication sutures were placed and the skin redraped.The result is shown
1 year after the secondary lift procedure.

These images show a patient 10 years after a primary face lift with scars as shown.
She returned requesting additional improvement and repositioning of the scars.
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The secondary procedure was designed to elevate the postauricular scars up higher
behind the ear and restore the gap in the hairline, elevate the midface, and tighten
the neck; an endoscopic brow lift was also performed. The postoperative result is
shown.

This patient is seen prior to a revision brow lift, face lift, and laser rejuvenation and
4 years, 5 months postoperatively.
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Seven months later the patient underwent a third procedure, including endobrow,
face lift, and rhinoplasty.
In this patient, 22 years elapsed from the time of her rst facial rejuvenation surgery
until she sought additional correction. No previous records were available.The op-
erative plan included additional correction of the lower lids, reelevation of the mid-
face, platysma repair, and fat injection in the nasolabial folds and oral commissures.
Additionally, we attempted to restore the tragus back to a more normal appear-
ance.37,38

The planned new incision is shown in relation to the old scars to attempt to make
these less conspicuous.
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A standard SMAS ap is marked just below the zygomatic arch to include the malar
fat pad and the lateral platysma. Fixation is to the malar periosteum and to the cut
edge of SMAS horizontally and vertically.
The tragal cartilage is transected and a 4-0 nylon suture is used to tie the tragal
remnant back to the conchal bowl as depicted above.The covering cheek skin ap
will then be stented by this tragal retaining suture for one week to prevent it from
being outwardly distracted.

The following case represents a longer term follow-up of a patient undergoing ter-
tiary face-lifting using the techniques described in this chapter.
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This 47-year-old woman presented with complaints of continued facial aging and
prominent scars following an initial face lift at age 36 and a mini-lift at age 41.The
presideburn scars are visible, as is descent of the malar fat pad and minor jowling.
A tertiary face lift that included an extended SMAS technique anchoring the malar
fat pad to the malar periosteum was performed, with the result seen at 1 year.

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At 4 years postoperatively, the result remains stable and the scars are improved. No
further procedures except skin care have been performed.
CONCLUSION
Our concepts of facial rejuvenation are continuously evolving and as this occurs, so
will the tools and techniques available to us for reoperative improvements. Aging
and surgery can both result in profound volumetric changes that conventional lift-
ing methods cannot always change. Similarly, surface wrinkling is a major problem
with our aging population, and correction can be disappointing with the surgical
techniques that are currently available. Nevertheless, our goal continues to be to
maintain a natural and youthful appearance, taking great care not to leave telltale
signs of our interventions.
References—With Key Annotated References
1. Ruess W, Owsley JQ.The anatomy of the skin and fascial layers of the face in aesthetic surgery.
Clin Plast Surg 14:677, 1987.
2. Letourneau A, Daniel RK. Super cial musculoaponeurotic system of the nose. Plast Reconstr
Surg 82:48, 1988.
3. Stuzin JM, Wagstrom L, Kawamoto HK, et al. The anatomy and clinical applications of the
buccal fat pad. Plast Reconstr Surg 85:29, 1990.
4. Freilinger G, Gruber H, Happak W, et al. Surgical anatomy of the mimic muscle system and the
facial nerve: Importance for reconstructive and aesthetic surgery. Plast Reconstr Surg 80:686,
1987.
5. Peterson RA, Johnston DL. Facile identi cation of the facial nerve branches. Clin Plast Surg
14:785, 1987.
6. Baker D, Conley J. Avoiding facial nerve injuries in rhytidectomy.Variations and pitfalls. Plast
Reconstr Surg 64:781, 1979.

7. Lemmon M. Super cial fascia rhytidectomy: A restoration of the SMAS with control of the
cervicomental angle. Clin Plast Surg 10:449, 1983.
8. Stuzin JM, Wagstrom L, Kawamoto HK, et al. Anatomy of the frontal branch of the facial
nerve:The signi cance of the temporal fat pad. Plast Reconstr Surg 83:265, 1989.
9. Furnas D.The retaining ligaments of the cheek. Plast Reconstr Surg 83:11, 1989.
10. Hamra S.The deep plane rhytidectomy. Plast Reconstr Surg 86:53, 1990.
11. Hamra ST. Composite Rhytidectomy. St Louis: Quality Medical Publishing, 1993.
12. Jones BM, Grover R. Avoiding hematoma in cervicofacial rhytidectomy: A personal 8-year
quest. Reviewing 910 patients. Plast Reconstr Surg 113:381; discussion 388, 2004.
The authors examined the effect of various parameters (that is, dressings, drains, fibrin glue, and
tumescent in ltration with and without epinephrine) on the rate of hematoma in this large consecu-
tive retrospective study. Only the omission of epinephrine signi cantly decreased the hematoma rate.
An incisive critical analysis of their results by the discussant suggests the restoration of normal blood
pressure and other factors may be more instrumental in achieving a low complication rate.
13. Matarasso A, Elkwood A, Rankin M, et al. National Plastic Surgery Survey: Face lift tech-
niques and complications. Plast Reconstr Surg 106:1185; discussion 1196, 2000.
Trends in the techniques used in rhytidectomy and complication rates and management of complica-
tions among American plastic surgeons were surveyed.The conclusions drawn were somewhat chal-
lenged by a 15% response rate, which was nonetheless statistically signi cant.The discussant added
conventional wisdom to this ambitious project.
14. Moyer JS, Baker SR. Complications of rhytidectomy. Facial Plast Surg Clin North Am 13:469,
2005.
15. Niamtu J III. Expanding hematoma in face-lift surgery: Literature review, case presentations,
and caveats. Dermatol Surg 31(9 Pt 1):1134; discussion 1144, 2005.
16. Kamer FM, Song AU. Hematoma formation in deep plane rhytidectomy. Arch Facial Plast
Surg 2:240, 2000.
17. Baker DC, Chiu ES. Bedside treatment of early acute rhytidectomy hematomas. Plast Recon-
str Surg 115:2119; discussion 2123, 2005.
The authors describe their technique for management hematomas following face-lift surgery using an
emergency “hematoma kit”at the bedside with monitoring with the patient under sedation and anal-
gesia. Contraindications are also discussed, such as delayed diagnosis, bilateral hematoma, and airway
compromise.With close perioperative monitoring and early diagnosis and treatment, costly return to
the operating room can be minimized.
18. Grover R, Jones BM,Waterhouse N.The prevention of hematoma following rhytidectomy:A
review of 1078 consecutive facelifts. Br J Plast Surg 54:481, 2001.
19. de la Cruz L, Berenguer B, de la Plaza R. Thromboembolism after face lift because of muta-
tion of the prothrombin gene. Plast Reconstr Surg 116:682, 2005.
20. Reinisch JF, Bresnick SD, Walker JW, et al. Deep venous thrombosis and pulmonary embolus
after face lift: A study of incidence and prophylaxis. Plast Reconstr Surg 107:1570; discussion
1576, 2001.
21. Baker DC, Stefani WA, Chiu ES. Reducing the incidence of hematoma requiring surgical
evacuation following male rhytidectomy: A 30-year review of 985 cases. Plast Reconstr Surg
116:1973; discussion 1986, 2005.
This is an excellent, well-written, well-organized, comprehensive retrospective study on the incidence
of hematoma in male rhytidectomy patients.The authors have provided an in-depth analysis of the
causative factors and recommended therapeutic and preventive measures for management of this most
common adverse event, including a very practical table of commonly used medication in the perioper-
ative period.
22. Christian MM, Behroozan DS, Moy RL. Delayed infections following full-face CO 2 laser
resurfacing and occlusive dressing use. Dermatol Surg 26:32-36, 2000.
23. Akers JO, Mascaro JR, Baker SM. Mycobacterium abscessus infection after facelift surgery: A
case report. J Oral Maxillofac Surg 58:572; discussion 574, 2000.
24. Jallali N, Lamberty BG. A rare and near fatal complication of rhytidectomy. Plast Reconstr
Surg 114:279, 2004.
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307
Chapter 11
Reoperative Rhytidectomy
25. Feingold RS. Parotid salivary gland stula following rhytidectomy. Plast Reconstr Surg 101:245,
1998.
26. Barron R, Margulis A, Icekson M, et al. Iatrogenic parotid sialocele following rhytidectomy:
Diagnosis and treatment. Plast Reconstr Surg 108:1782; discussion 1785, 2001.
Recently there have been more reports of parotid stulas and pseudocysts associated with SMAS dis-
section during rhytidectomy.This is a case report of a parotid sialocele associated with Stensen’s duct
obstruction and paresis of the mandibular branch of the facial nerve in which the authors used sialog-
raphy and an endoscopic exam of Stensen’s duct as management tools.The discussion, by Dr. Stuzin,
gives helpful guidelines for prevention and management of this distressing complication of facial aes-
thetic surgery.
27. Lapid O, Kreiger Y, Sagi A.Transdermal scopolamine use for post-rhytidectomy sialocele. Aes-
thetic Plast Surg 28:24, 2004; Epub May 3, 2004.
28. Daane SP, Owsley JQ. Incidence of cervical branch injury with “marginal mandibular nerve
pseudo-paralysis” in patients undergoing face lift. Plast Reconstr Surg 111:2414, 2003.
29. Hamra ST. Correcting the unfavorable outcomes following facelift surgery. Clin Plast Surg
28:621, 2001.
30. Hamra ST.Frequent face lift sequelae:Hollow eyes and the lateral sweep:Cause and repair.Plast
Reconstr Surg 102:1658, 1998.
31. Little JW. Applications of the classic dermal fat graft in primary and secondary facial rejuvena-
tion. Plast Reconstr Surg 109:788, 2002.
32. De Cordier BC, de la Torre JI, Al-Hakeem MS, et al. Rejuvenation of the midface by elevat-
ing the malar fat pad: Review of technique, cases, and complications. Plast Reconstr Surg
110:1526; discussion 1537, 2002.
33. Brennan HG,Toft KM, Dunham BP, et al. Prevention and correction of temporal hair loss in
rhytidectomy. Plast Reconstr Surg 104:2219; discussion 2226, 1999.
34. Connell BF, Shamoun JM. The signi cance of digastric muscle contouring for the rejuvena-
tion of the submental part of the face. Plast Reconstr Surg 99:1586,1997.
35. Guyuron B, Bokhari F, Thomas T. Secondary rhytidectomy. Plast Reconstr Surg 100:1281,
1997.
36. Guyuron B. Secondary rhytidectomy. Plast Reconstr Surg 114:797, 2004.
Sequelae such as malposition of the sideburn, earlobe deformity, hypertrophic scars, loss of tragal def-
inition, uncorrected marionette lines, and neck contour irregularities are often associated with second-
ary rhytidectomy.The author discusses some of his methods for the prevention and correction of these
problems and guidelines for laser skin resurfacing combined with rhytidectomy.
37. Brink RR. Auricular displacement with rhytidectomy. Plast Reconstr Surg 109:408, 2002.
38. Mowlavi A, Meldrum DG,Wilhelmi BJ, et al.The “pixie” ear deformity following face lift sur-
gery revisited. Plast Reconstr Surg 115:1165-1171, 2005.

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1. The SMAS:
a. Is generally thicker in reoperative rhytidectomy
b. Is easily elevated in secondary rhytidectomy
c. Is a discrete fascial layer that separates the overlying subcutaneous fat from
the underlying parotidomasseteric fascia and facial nerve branches
d. Is of uniform thickness from the super cial cervical fascia to the super -
cial temporal fascia
e. Is thickest over the malar region
2. All of the following muscles receive their innervation from their deep surfaces
except:
a. Platysma
b. Orbicularis oculi
c. Levator anguli oris
d. Zygomaticus major
e. Zygomaticus minor
3. The risk factors for hematoma include all of the following except:
a. Hypertension
b. Male sex
c. Bleeding disorders
d. SMAS undermining
e. Aspirin usage
4. Bedside management of hematomas should be avoided in all of the following
except:
a. Uncooperative patient
b. Unilateral postauricular swelling
c. Labile blood pressure in a 50-year-old man
d. Bilateral hematomas
e. Compromised airway
5. The primary management of a parotid stula is:
a. Ductal cannulation
b. Parotidectomy
c. Atropine
d. Drainage
e. Sialography
R EVIEW QUESTIONS

309
Forehead lifts have earned an enduring place in the repertoire of surgeons who
perform facial rejuvenation procedures.This operation makes an undeniably signif-
icant contribution to facial rejuvenation, as demonstrated by the preoperative and
postoperative views of three different patients on p. 310. Like upper and lower
blepharoplasties, forehead lifts are frequently once in a lifetime operations; reoper-
ation is rarely required. However, secondary procedures are not unheard of.
A solid knowledge of the vascular anatomy of the forehead, gentle technical dissec-
tion, mastery of tension, and careful strategic planning are key components of any
reoperative procedure to ensure consistent, natural results.
Reoperative Forehead Lift
Brunno Ristow
C ha pter 12
Reoperative Problems
Scar depression and contour defects
Recurrent brow ptosis or asymmetry
Unacceptable hairline scar
Paralyzed forehead
Residual rhytids
Elevated hairline
Hair loss
Our knowledge is the amassed thought
and experience of innumerable minds.
Ralph Waldo Emerson

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Preoperative and postoperative views are shown following forehead lift and face
lift in three patients.

VASCULAR ANATOMIC CONSIDERATIONS
Knowledge of how the blood supply may have been altered by the primary brow
lift is of paramount importance in planning a reoperative brow lift procedure.The
surgeon must address the following questions to outline a safe and effective second-
ary operation:
Is the supratrochlear artery intact?
Is the super cial temporal artery intact?
Is the anastomosis between the two arteries intact?
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Chapter 12
Reoperative Forehead Lift
Possible site of injury
(less frequent)
Supraorbital artery
Supratrochlear artery
Possible site of injury
Ophthalmic artery
Lateral nasal artery
Facial artery
Superficial temporal artery
Site of commonly performed division
External carotid artery
Internal carotid artery
Common carotid artery
After A. von Ristow, MD
The super cial temporal artery has its major anastomoses with the supratrochlear
artery and alternative branches to the supraorbital artery. To further mobilize the
upper face for either facelift or brow lift, many surgeons divide the super cial tem-
poral artery. The division of this artery at the upper pole of the anterior aspect of
the ear does not appear to cause ill effects provided the anastomosis of the super-
cial temporal artery to the supratrochlear artery on that same side remains intact.1

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To determine the status of these arteries, digital pressure is applied to the super -
cial temporal artery over the zygomatic bone to occlude this vessel, thus increasing
compensatory blood flow within the supratrochlear artery. A portable Doppler
owmeter placed over the course of the supratrochlear artery (above, left) on the
upper lateral side of the nose will, within 3 seconds, double its audible sound, attest-
ing to the patency of the anastomosis.The probe (above, right) con rms the position
of the super cial temporal artery.
One should always consider the possibility that the previous surgeon may have li-
gated the supratrochlear or supraorbital arteries. In this case, the frequently per-
formed division of the super cial temporal artery would have a deleterious effect
on the viability of the hair follicles.
In rare circumstances the arterial anastomosis between the super cial temporal and
supratrochlear systems can provide an important alternative blood supply to the
brain by retrograde ow. I know of one patient, a 56-year-old man, kept alive by a
single unilateral patent sequence of this particular anastomosis.2 This patient, a
smoker and neurologically asymptomatic, had complete occlusion of the left in-
ternal carotid artery by progressive arteriosclerotic disease and 80% stenosis of the
right internal carotid artery. Since these obstructions progressed over a period of
time, the circulation gradually adapted to these changes in the vasculature.
The location of this anastomosis be-
tween these two arteries is low within
the forehead, and even a hairline fore-
head incision is extremely unlikely to
injure the arterial network as shown in
this intraoperative view. The tip of the
Ragnell scissors points to the super -
cial temporal artery in its normal low
course where it anastomosis with the
supratrochlear artery.

As demonstrated in this angiogram, the blood supply to the brain was maintained
by the anastomosis of the left external carotid artery to the left super cial tempo-
ral artery. From there the blood owed to the left supratrochlear artery and then,
by retrograde ow, coursed to the ophthalmic artery to irrigate the brain.The large
arrow points to the intracerebrally located carotid siphon.This is not a rare nding
in patients with bilateral carotid vascular disease. Of course, division of the super-
cial temporal artery on the left side, which is routinely performed in forehead
lifts or facelifts, in this case would have had tragic consequences.
The implication is clear: when dissecting the corrugator muscles in the glabellar
area, one must use extreme caution to avoid injury to the supratrochlear artery and
the supraorbital artery.This dissection is best performed with Potts tenotomy scis-
sors by gently divulsing and cutting the bers of the corrugator muscles, preserv-
ing intact all arteries, veins, and nerves.The dissection is not dif cult, but it must be
performed with care. Passing one limb of a mosquito clamp behind the corrugator
muscle and then clamping and dividing the muscle is too dangerous; the supra-
trochlear artery could conceivably be cut. If this occurs and the super cial tempo-
ral artery on the same side has been previously ligated, the blood supply to the sen-
sitive follicles is seriously jeopardized and eventual thinning or even loss of the hair
is not only possible but very likely. My personal understanding of these anatomic
interactions in the last few years has been the single most important factor in allow-
ing me to plan strategically sound reoperations for forehead lifts.
BASIC TECHNIQUE FOR PRIMARY
FOREHEAD LIFT
Because many problems requiring reoperation could be prevented if adequate con-
sideration had been given to certain factors in the primary procedure, a brief dis-
cussion of the basic forehead lift technique is merited. For example, in the primary
operation the surgeon may not have addressed anatomic structures such as the cor-
rugator and occipitofrontalis muscles, and consequently the patient has had an early
recurrence of the preoperative appearance.
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Reoperative Forehead Lift
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R EOPERATIVE SURGERY OF THE HEAD AND NECK
Incision in galea aponeurotica
Bicoronal incision
Regardless of the type of incision employed, I always leave the cuff of galea on the
cephalad incisional edge. This cuff helps to create a solid and level postoperative scar.
The ap is elevated sharply using a No. 10 Personna Plus blade, and the dissection
is extended just above the zygomatic arch and short of the emergence of the neu-
rovascular bundles. From this region forward, the dissection is performed bluntly
with a peanut dissector. It is important to preserve orbital retaining structures so that the
eyebrow does not raise to an unnatural level.The corrugator muscles are exposed,
as is the upper fourth of the nasal bone. A Ragnell scissors is used to elevate the
nasal skin for approximately 1 cm in width through the entire length of the nose.3
This maneuver allows the skin of the upper vault to drape upward, which can of-
ten make a short nose appear longer and more elegant. This technique also subtly
elevates the tip of the nose.
These preoperative and postoperative
profile views demonstrate the subtle
but noticeable lift of a ptotic nose that
was obtained by simply undermining
the dorsum during a forehead lift.

The Potts tenotomy scissors is now used to divulse the bers of the corrugator
muscles.Veins, large and small arteries, and nerves are always preserved.The cepha-
lad and caudad stumps of the corrugator muscles are excised.The procerus muscle
is generally not altered at all. When division of the procerus muscle is considered
to alleviate transverse creases of the skin of the upper one third of the nose, a sin-
gle division is made low to avoid creating any depression contour deformities. Con-
nell’s method4 of dividing the procerus muscle below the skin creases and under-
mining it from its subcutaneous tissues is an excellent maneuver as well.
The occipitofrontalis muscle also merits careful consideration. Leaving the oc-
cipitofrontalis muscle intact has distinct advantages; one must remember that the
occipitofrontalis muscle elevates the eyebrows, an important facial expression that
communicates friendliness and interest. For this reason signi cant excision of the
occipitofrontalis muscle has properly been abandoned.4
Anatomically the occipitofrontalis muscle is actually two muscles, one on the right
and one on the left. They begin their diversion from one another at the glabellar
level. The occipitofrontalis muscle is separated from the pericranium by a layer of
specialized tissues that allow gliding of the forehead skin over the frontal bone. It is
my experience that this tissue is the best donor site for harvest of the insulating
and bulk-correcting graft in the glabella.
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Chapter 12
Reoperative Forehead Lift
Two different designs of the gliding tissue graft
are used.The rst is in the shape of an anvil and
provides two limbs to surround each set of neu-
rovascular bundles. With the harvest of the au-
tograft, a shallow, inclined V is created in the re-
maining occipitofrontalis muscle. During lateral
animation this V effectively camouflages the
transitional zones between muscle and fascia.

Galeal graft
Limb A
Limb B
Right supratrochlear
neurovascular bundle
Right supraorbital
neurovascular bundle
Orbicularis oculi muscle
Procerus muscle
Occipitofrontalis muscle
Scalp reflected forward
Galea aponeurotica
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R EOPERATIVE SURGERY OF THE HEAD AND NECK
The second, which is more common, is shaped like a triangle; once harvested, the
graft is notched on two sides to create the limbs necessary to encompass the neu-
rovascular bundles. The advantages of the latter design are that (1) the forehead
ap, partially devoid of its gliding tissues, heals at a higher level, thus elevating the
eyebrows, and (2) the occipitofrontalis muscle remains intact for animation and ex-
pression.
The dynamics of the glabella must be understood. The division of the corrugator
muscles (and rarely of the procerus muscle) permits the overlying skin to be ele-
vated and smoothed. Of course, this is one of the main objectives of the operation.
However, the same amount of skin now covers a much greater area.Without an au-
tograft in place to correct the volume de cit caused by the severance and removal
of the corrugator muscles, stretching of the skin over a larger area results in a glabel-
lar depression, as evident in this patient. Furthermore, without correction by auto-
graft, the small stumps of the corrugator muscles may reattach themselves, causing
animation of the overlying forehead skin.5

Stumps of corrugator muscle
Limb A of graft
Limb B of graft
Occipitofrontalis muscle
Left supraorbital
neurovascular bundle
Galea aponeurotica
Donor site of galeal graft
Galeal graft sutured
to pericranium
Pericranium
Galeal cuff
Scalp
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Chapter 12
Reoperative Forehead Lift
Thus the use of an autograft of the naturally gliding tissues in the glabella is logi-
cal. On rare occasions this graft may include some occipitofrontalis muscle bers.
The extensions of the graft are passed cephalad and caudad to the neurovascular
bundles on the right and left. Sometimes, I place the mid-portion of the graft be-
tween the procerus muscle and the overlying subcutaneous tissues. However, with
5-0 Monocryl sutures, the graft is always secured around the neurovascular bundles.

318
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R EOPERATIVE SURGERY OF THE HEAD AND NECK
Key sutures placed and
excess scalp removed
Undermined to nasal tip
A 10 Fr smooth, fluted, silicone drain is placed (for example, the Jackson-Pratt
Hemaduct REF JP-HUR 100), exiting from either the right or left supraauricular
scalp. A tension-determining D’Assumpçao clamp is used in ve locations:two on
the right, one in the center, and two on the left. The clamp is used to mark the
galea below the ap and not on the skin above. (The ink is placed on the dorsum of
the clamp’s upper arm as opposed to the underside.) A 3.0 clear Monocryl suture
secures the ap galea to the cuff galea.The scalp is then redraped with some redun-
dancy (so minimal hair is removed) and closed with 4.0 Prolene. In this fashion a
solid fascia-to-fascia closure is ensured.
PATIENT EVALUATION FOR SECONDARY
FOREHEAD LIFT
Examination of a patient who may bene t from a secondary brow lift can be sim-
ple or complex. The most common complaint of the patient seeking reoperation
following brow lift is that the result “did not last and I have all the frown lines
back.” If the hairline of such a patient is in an acceptable or even low position, the
correct technical execution of a bicoronal forehead lift operation will achieve a
very pleasing result. If the hairline is already high and the patient is not a smoker,
a subcutaneous forehead lift with the incision at the hairline is indicated.

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SPECIFIC PROBLEMS
SCAR DEPRESSION AND CONTOUR DEFECTS
A common complaint of brow lift patients is depression of the scalp at the previ-
ous incision sites.
To prevent the creation of a postoperative scar depression, the initial
incision should advance through the scalp and subcutaneous fat but
not through the galea.6
The caudad ap is then elevated with a double-prong nasal hook and dissected free
from the underlying galea.The various vessels that overlie the galea can be coagu-
lated easily because they are clearly visible. Electrocautery injury to the cephalad
follicles is unlikely because of the distance of the cautery from the cephalad scalp.
Approximately 1.5 cm from the scalp’s cephalad incision, the galea is divided. Es-
sentially the entire cephalad incision is bordered by a galea cuff approximately 1.5
cm in width.The follicles in the caudad ap usually incline forward. Consequently,
when trimming the excess strip of scalp, the surgeon must angle the knife so that
it is parallel with the orientation of the follicles. As a corollary, the cephalad galea
will project and be visible under the scalp incision. At the time of wound closure,
the caudad cuff of galea will be established.This re nement prevents depressions of
the scar because it ensures a solid, deep double layer of galea healed by a strong, in-
elastic scar, which supports the scalp above. This strategy avoids the occurrence of
wide, depressed, or glabrous areas.With time these scars become inconspicuous.
If a patient presents with glabrous areas or the depressed contour of scalp suture
lines, the surgeon should determine whether the posterior scalp has retained a
measurable gliding ability. If so, a signi cant mobilization of the scalp will provide
a tension-free closure, which is essential to the survival of the hair follicles at the in-
cisional line. If at all possible, the galea should be doubled under the incisional line.

ROLE OF FAT INJECTION
Fat transfers, if properly performed, will survive in their new location. However,
maintaining the exact contour or volume is not predictable;therefore I use fat grafts
only in locations in which precise long-term volume and contour are not of para-
mount importance. For optimal survival, fat grafts must be placed between two soft
surfaces, not between a soft surface and a bone.
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PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
This patient underwent a fat graft to the glabella between the corrugator muscle
and the dermis. At 8 months postoperatively, the right side of the graft had ab-
sorbed partially, whereas the left side of the graft had survived intact, creating a
slight projecting bulge.This problem was resolved by repeated injections of 0.5 mg
of triamcinolone (Kenalog) into the graft over a period of weeks.
This patient exhibits the same problem:equal fat grafts of identical origin and vol-
ume were placed over the malar bones.Two years postoperatively, the survival of the
right malar graft remains complete, whereas the graft on the left only partially sur-

321
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Reoperative Forehead Lift
vived. If these grafts had been placed in the midface below the zygomatic arch,
these differences would not be so apparent. Therefore, because of their unpre-
dictable survival, fat grafts are not indicated in the glabellar region.
UNACCEPTABLE HAIRLINE SCAR
Problems with an unacceptable hairline scar are inextricably linked to the brow-lift
technique employed and may be very dif cult to correct if the defect is signi cant.
Before agreeing to attempt a correction, the surgeon must establish if the motility
of both cephalad and caudad aps will allow a tension-free closure.
If tension on closure is inevitable, the key suture that bears the tension
must be placed inside the hair—never at the hairline closure.
Two techniques can be performed to achieve an optimal hairline scar in the fore-
head.In the rst technique the incision follows the contour of each hair and its cor-
responding follicle, and the cut is extended through the galea.The surgeon can lit-
erally see each hair extend down through the entire depth of the subcutaneous
tissue. After closure, the hair shafts will emerge at the incision line or minimally (less
than 1 mm) behind it.7
In the second technique, which I prefer, the incision is made at an acute angle with
the knife inclined very substantially forward, leaving one, two or three follicles of
hair in front of the incision.The caudad ap is trimmed so that it follows the same
beveled angle.The result is that one or two follicles remain under the thinnest pos-
sible epidermal-dermal cover, and these hairs will emerge at the scar or slightly in
front of it.
These incisions must be closed without tension and with very ne sutures. My
preference is 6.0 clear Monocryl.
A closeup view of an incision at the hairline, as described earlier. Note that scars are
virtually invisible.

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R ESIDUAL R HYTIDS
If the primary brow lift did not address the corrugator muscles, the reappearance of
frown lines may occur in only a matter of weeks. A judicious approach to the cor-
rugator muscles is indispensable.The patient’s wishes for retained expression, which
is especially important for individuals in certain professions (for example, trial
lawyers, clerics, professors, judges, actors, and actresses), must be taken into
consideration. Only the corrugator muscles should be divided or excised. Muscles
that surround the corrugator muscles must be preserved, otherwise noticeable lat-
eral migration of the medial ends of the eyebrows can occur.The statement,“Doc-
tor, I don’t ever want to see those lines again!” by a prospective patient should be
countered with an explanation that some muscles must be left in place; otherwise,
the eyebrows will diverge. Here the galea autograft also plays an important role by
keeping these structures (for example, neurovascular bundles) at their correct posi-
tion postoperatively.
Recurrence of occipitofrontalis muscle rhytids must be approached with caution. Of
course, there are patients with a massive, hypertrophied occipitofrontalis muscle.
My preference in this case is to remove lateral strips of 1 cm of occipitofrontalis
muscle across the forehead. For this thinning procedure, meticulous care should be
exercised to preserve the ascending neurovascular bundles intact. I do not think
the occipitofrontalis muscle should ever be completely excised, only thinned, using
a curved scissors. Either Stille8 scissors or Potts tenotomy scissors accomplish this
task effectively.
HAIR LOSS
Experienced surgeons are likely to have been consulted by at least one patient who
has suffered disastrous hair loss at the incision line from either a forehead lift or
facelift. I have examined women who had been operated on elsewhere whose hair
anterior to the incision was completely lost on both sides. More frequently a patient
complains of the hair having “thinned out” after surgery.These problems are dif -
cult to correct. In my opinion three conditions can be responsible for such a dev-
astating and complex complication:(1) surgical dissection too super cial, with sub-
sequent injury to the hair follicles and subdermal vascular plexus, (2) excessive
tension, and (3) injury to the main arteries nourishing the ap.
If the intricacies of the arterial network are completely understood by the operat-
ing surgeon, hair loss from vascular injury will be extremely rare. Hair loss may
also be caused by failure of the surgeon to observe the different inclinations of the
hair shafts and corresponding follicles and to preserve their integrity. For instance,
just above the ear, the hair shafts often sharply incline backward, with the emerg-
ing hair posterior to the follicles. Approximately 1 inch above that point, the incli-
nation is neutral, but then again, above this area, the inclination is usually forward.
Clearly, the recommendation is to make the incision parallel the inclinations of the
hair shaft.These hair shaft inclination patterns differ from one patient to the next.

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Reoperative Forehead Lift
The correction of problems of hair loss is complex. Hair transplants offer a possi-
ble solution, but if the loss is secondary to impaired blood supply, transplanted hair
is subject to the same limitations. For hair loss of undetermined origin (when the
arterial network is known to be intact), minoxidil applied twice a day is suggested
and appears to have a positive effect because of its vasodilative action.
An additional cause of hair loss is the subcutaneous implantation of testosterone
pellets in postmenopausal or oophorectomized women. Insuf cient estrogen levels,
impaired thyroid function, or increased androgen levels of any kind produce hair
loss. Particularly devastating hair loss can occur in women who are receiving a com-
bined estrogen-testosterone oral medication to increase the libido level.The char-
acteristic of this type of hair loss is that it is generalized and not segmental, as in
forehead-lifted aps.
R ECURRENT BROW PTOSIS OR ASYMMETRY
The recurrence of brow ptosis is probably the most common indication for brow
lift reoperation. In such cases, very likely a conservative rst operation was per-
formed in which the muscular problems were not addressed, the gliding tissue was
not harvested, and therefore the forehead was not secured at a higher elevation. A
reoperation in which these issues are addressed should produce a satisfying result.
The practice of direct excision of excess forehead skin is controversial at best. I have
seen a number of patients dissatis ed with the resulting scar.If such an attempt is made,
the excision should be subcutaneous. The surgeon must also consider that the resulting
elevation of the brow may not be uniform between the medial and lateral portions
of the eyebrow.Theoretically, elevation of the eyebrow, lowering of the hairline, and
avoidance of muscle surgery are all advantages of a “direct excision.” The resulting
scars can be very disappointing, however, even with the nest closure performed.
Specialized publications refer to various formulaic operative procedures that will sup-
posedly secure the eyebrow at a certain elevation postoperatively. I have not used
such methods mainly because I believe that multiple unpredictable variables (for ex-
ample,tissue strength,age,damage from sun) invalidate these approaches.The general
rules for me are to (1) dissect to the orbital rims—no more, no less, (2) use tension-
determining clamps (that is, a D’Assumpçao clamp)9 judiciously at the time of clo-
sure, and (3) preserve the natural brow-retaining structures to avoid undo elevation.
In my opinion, few errors produce as unnatural a look as an overly elevated brow.
In terms of brow asymmetry, the patient and the surgeon must remember that
asymmetry of the face is not only common but usually present in even the most at-
tractive people. A patient whose foremost desire is symmetry should be examined
guardedly as perfect symmetry is an unattainable goal. A large degree of asymme-
try can be ameliorated by freeing the superior periorbital attachment of the lower
eyebrow, but not of the higher eyebrow.The patient must be advised before the op-
eration that exact symmetry is impossible to obtain because of variations in tissue.

PARALYZED FOREHEAD FROM FRONTAL BRANCH INJURY
The frontal branch of the seventh cranial nerve is well protected from injury. The
nerve is deeply located in the face, emerging from under the parotid gland approx-
imately 0.5 cm in front of the tragus. It ascends deep, crosses the zygomatic bone,
literally hugging its arch, and advances deep to the occipitofrontalis muscle be-
tween the muscle and its deep fascia. It courses quite anterior to the super cial
temporal artery, a fact that is of major importance.
With the advent of more extensive procedures, such as dissecting to the zygomatic
arch, the potential for injury of the frontal branch of the seventh cranial nerve has
become a true possibility. I decided to examine this risk by localizing the nerve on
the underside of the ap. On the skin a line was traced starting 0.5 cm in front of
the lower aspect of the tragus and superiorly passing 2 cm from the lateral aspect of
the eyebrow. With a C-Line Vary-Stim RIII nerve stimulator set at 1⁄2 mA, I then
probed for this nerve and found the following:
1. The position of the nerve in 20 patients was, for practical purposes, con-
stant and very closely re ected the line marked on the skin.
2. The nerve was mostly single! Probing with the stimulator both cephalad
and caudad of the nerve did not elicit further movement of the muscles.
3. The nerve is visible on the underside of the ap as a small, thin, 0.5 mm l-
ament. Its accompanying vessel is also frequently visible.
The conclusion is that injury to the frontal branch during forehead lifts is quite
possible if precise plane dissection is not followed.With the Daniel forehead eleva-
tor I dissect until the I feel the resistance of the attachments of the fascia to the zy-
gomatic arch. Further elevation at the cost of entering the area of the super cial
temporal fat pad appears to produce negligible gain and perhaps causes potential loss
of this important volumetric anatomic structure.
324
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Zygomatic
branches
Buccal
branches
Superficial
temporal
artery
Frontal
(temporal)
branch
Marginal
mandibular
branch
Injury to the frontal branch is more com-
mon during facelifts if deviation from safe
planes of dissection occurs. The study of
Terzis’remarkable dissections of the facial
nerve is recommended and should orient
the surgeon properly.